Not Just a Linear Closure: Aesthetic Flat Closure after Mastectomy

"Microsurgical breast reconstruction - A salvage option for failed implant-based breast reconstruction"

BACKGROUND

The objective of this study was to evaluate microsurgical breast reconstruction as a salvage option for patients with failed implant-based breast reconstruction.

METHODS

We conducted a retrospective single-center study including all patients with failed unilateral implant-based breast reconstruction who elected to undergo conversion surgery to microsurgical breast reconstruction from January 2015 to December 2023. Patients were grouped according to the urgency for conversion surgery in the urgent (implant infection or extrusion) or elective (capsular contracture, patients' desire) group. Both groups were compared.

RESULTS

120 patients were included in the study. 101 patients (84 %) were grouped in the elective group and 19 patients (16 %) in the urgent group. Patient characteristics and intraoperative variables including the utilization of DIEP/MS-TRAM and TMG flap for microsurgical reconstruction were similar in group comparison. Patients in the urgent group had significantly more surgical interventions (3.3 vs. 2.0, p < 0.001) and suffered from significantly more major complications requiring re-operation (32 % vs. 11 %, p = 0.018) compared to the elective group. There was one flap loss in the urgent group (5 % vs. 0 %, p = 0.158).

CONCLUSION

Microsurgical breast reconstruction is a reliable and safe salvage option in patients with failure of implant-based breast reconstruction. Urgent conversion to microsurgical breast reconstruction due to implant-associated complications, such as infection or extrusion, requires more surgical interventions to achieve successful breast reconstruction and has a higher rate of major complications compared to elective conversion.

Post-Mastectomy Flat Closure: A Mixed-Methods Analysis of Patient Outcomes and Perspectives

BACKGROUND

Understanding the psychosocial impact of mastectomy is crucial for guiding patient decisions on breast reconstruction. The BREAST-Q survey has been instrumental in assessing patient satisfaction. This study examines patient-reported outcomes and experiences with post-mastectomy flat closure, aiming to refine decision-making support for this option.

METHODS

A retrospective review analyzed flat closure outcomes post-mastectomy, examining patient demographics, surgical details, and complications. Following consent, patients completed the BREAST-Q survey, rating satisfaction and factors influencing their choice for flat closure. The study also included qualitative analysis from patient emails, employing an inductive, triangulated approach to extract themes and provide a multifaceted understanding of the post-surgical experience.

RESULTS

Overall, 252 patients underwent flat closure post-mastectomy. The overall postoperative complication rate was 17.5% (n = 44); 19.8% (n = 50) completed the BREAST-Q survey, reporting high satisfaction with their surgeons, moderate satisfaction with their breasts, and high physical well-being. Survey results illuminated reasons for choosing flat closure, such as lower complication rates and avoidance of foreign objects. Furthermore, qualitative feedback from 15 email correspondents revealed some limitations of the survey's relevance and language, highlighting emotional impacts and a desire to improve future surveys.

CONCLUSIONS

This study distills the flat closure experience post-mastectomy, highlighting its viability and alignment with patient preferences for fewer complications and quicker recovery. It reveals the BREAST-Q's limitations in fully capturing patients' nuanced experiences, underscoring the necessity for more tailored data collection methods. Future research must refine patient-reported outcome measures (PROMs) and ensure flat closure is a routinely discussed option in post-mastectomy care.

"Are you ready?" A longitudinal interpretative phenomenological analysis of couples' experiences with breast reconstruction decision-making

PURPOSE

In this study, we aimed to explore women's and their male partners' experiences with breast reconstruction (BR) decision and to study the evolution of their experiences since undergoing mastectomy to one year after.

METHODS

Unstructured individual interviews with four couples facing mastectomy for breast cancer and BR decision-making were conducted following mastectomy (T1) and one year after mastectomy (T2). Longitudinal interpretative phenomenological analysis (LIPA) was conducted on the data.

RESULTS

A total of 16 interviews were conducted, revealing seven group experiential themes: six applicable across time and one related to a specific timepoint. The results highlight two critical aspects: the ambivalence surrounding BR and the perceived importance of moving forward. Women and their partners expressed mixed feelings about BR, weighing the potential for improved quality of life and body image against fears of surgery and medical complications. The decision to undergo BR evolved over time, influenced by experiences related to body acceptance, aesthetic considerations, practical concerns, and societal norms for femininity. Partners played a significant role in the decision-making process, offering emotional support and influencing the decision both directly and indirectly. Moreover, the interpretative accounts underline how couples may see BR as a strategy for repairing both physical and psychological damage.

CONCLUSION

Our findings emphasize the importance of understanding BR not only as a medical procedure but also as a deeply psychosocial process shaped by individual and relational factors. Furthermore, we provide reflections on the use of LIPA since it is a rarely used method.

Disparity Reduction in U.S. Breast Reconstruction: An Analysis from 2005 to 2017 Using 3 Nationwide Data Sets

BACKGROUND

Following passage of the Women's Health and Cancer Rights Act of 1998 (WHCRA), a steady rise in breast reconstruction rates was reported; however, a recent update is lacking. This study aimed to evaluate longitudinal trends in breast reconstruction (BR) rates in the United States and relevant sociodemographic factors.

METHODS

Mastectomy cases with and without BR from 2005 through 2017 were abstracted from the National Surgical Quality Improvement Program database; the Surveillance, Epidemiology, and End Results Program database; and the National Cancer Database (NCDB). BR rates were examined using Poisson regression. Multivariable logistic regression analysis of NCDB data were used to identify predictors of reconstruction. Race and insurance distributions were evaluated over time.

RESULTS

Of 1,554,381 mastectomy patients, 507,631 (32.7%) underwent BR. Annual reconstruction rates per 1000 mastectomies increased from 2005 to 2012 (National Surgical Quality Improvement Program incidence rate ratio [IRR], 1.077; Surveillance, Epidemiology, and End Results Program IRR, 1.090; and NCDB IRR, 1.092) and stabilized from 2013 to 2017. NCDB data showed that patients who were younger (≤59 years), privately insured, had fewer comorbidities, and underwent contralateral prophylactic mastectomy were more likely to undergo BR (all P < 0.001). Over time, the increase in BR rates was higher among Black (252.3%) and Asian (366.4%) patients than among White patients (137.3%). BR rates increased more among Medicaid (418.6%) and Medicare (302.8%) patients than among privately insured patients (125.3%).

CONCLUSIONS

This analysis demonstrates stabilization in immediate BR rates over the past decade; reasons behind this stabilization are likely multifactorial. Disparities based on race and insurance type have decreased, with a more equitable distribution of BR rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Variation in surgical treatment by body mass index in patients with invasive lobular carcinoma of the breast

PURPOSE

Patients with invasive lobular carcinoma (ILC) face high rates of positive margins and completion mastectomy, which can be improved with the use of specific techniques, such as oncoplastic surgery. However, prior studies have shown that type of breast cancer surgery performed is also associated with patient factors such as elevated body mass index (BMI). Thus, this study investigates whether BMI impacts the type of surgical interventions in patients with ILC.

METHODS

A retrospective analysis of 705 patients with stage I-III ILC from an institutional database was conducted. Patients were stratified by BMI (underweight, normal weight, overweight, obese). Pearson's Chi-square, ANOVA, and multivariable logistic regression were used to evaluate the relationship between BMI and surgical procedures.

RESULTS

Breast-conserving surgery (BCS) was the initial operation in 60% of patients, with no significant difference by BMI. Among those undergoing BCS, patients with obese BMI were significantly more likely to undergo oncoplastic surgery (46.9% vs. 7.7%, 37.3%, and 33.6% for underweight, normal, and overweight, respectively, p = 0.032). Obese BMI patients undergoing mastectomy were less likely to have reconstruction compared to those with underweight, normal weight, and overweight BMI (44.2% vs. 50%, 71.1%, and 64.1%, p = 0.002).

CONCLUSION

Overweight/obese BMI patients with ILC underwent different surgical interventions compared to those with lower BMI. While initial BCS rates were similar, overweight/obese patients had higher oncoplastic surgery rates in BCS and lower reconstruction rates in mastectomy. Further research is needed to understand BMI's impact on surgical decisions and outcomes in ILC.

Women's experiences of health care providers when choosing flat closure after breast cancer: An interview study

PURPOSE

The purpose of this study was to explore women's experiences with healthcare providers previous to a flat closure after breast cancer.

METHODS

Data was collected using individual semi-structured interviews by telephone or teleconferencing systems with 18 women who shared their experience with health care before and during flat closure operation after breast cancer or a breast gene mutation. The interviews were transcribed verbatim and analyzed using thematic analysis.

RESULTS

The analysis generated three specific themes: (1) Striving to be recognized as a person, (2) Barriers to shared decision making and (3) A need to be empowered, indicating that women's views are not always illuminated and enquired about by health care providers. The care agenda was also more often regulated by norms and standard care than the individual women's intended goals. Furthermore, when the agenda for surgery had been previously set, the women were not presented with viable options to choose from for the upcoming surgery. For these women to influence the reality they face, they have to seek support outside of healthcare. This indicates the important role of patient networks and relatives in empowering the individual women to stand up for their choice and body.

CONCLUSION

In order to offer feasible surgery for women diagnosed with breast cancer or a breast mutation gene, the women's wishes regarding flat closure and what matters to her in her life must be identified. Also emphasized is the need for a more systematic approach in involving the affected women in shared decision-making.

Advocating for Enhanced Patient Engagement in Breast Cancer Care: Impact of Residual Increased Lateral Adiposity and Consideration of the Pursuit of "Living Flat"

Breast cancer is a significant health concern, accounting for a substantial proportion of cancer cases. Despite improvements in cancer survivorship, many women still require mastectomy as part of their therapeutic treatment. Mastectomy alone or delayed breast reconstruction (DBR) are two options available to women not suitable for immediate breast reconstruction at initial mastectomy. However, the presence of increased lateral adiposity (ILA) following mastectomy, commonly referred to as ``dog-ears,'' can lead to discomfort and aesthetic concerns. This paper explores the benefits and harms of ILA postmastectomy and its impact on patient satisfaction when choosing between mastectomy alone or DBR. A literature search was completed within OVID Medline, 1946-current, with the following terms, filtered for relevance: "mastectomy," "autologous reconstruction," "scar," "body image/dysmorphia," "patient-reported outcomes," "reconstructive surgical procedures/excess skin," "surgical flaps/dog ear." The disparity between clinical support and educational resources available for patients considering DBR options compared to those choosing mastectomy alone or pursuit of "living flat" is discussed. A common theme from qualitative research was the reported feeling of lack of inclusion in reconstruction planning by the patient. There were instances reported of residual skin remaining postmastectomy, against patient wishes. The findings emphasized the importance of shared decision-making and comprehensive preoperative education to ensure that patients are well-informed and satisfied with their chosen treatment approach. Further research is needed to address the specific needs and preferences of patients opting for mastectomy and to improve surgical techniques and education regarding living-flat options.

Women's decision process when actively choosing to 'go flat' after breast cancer: a constructivist grounded theory study

OBJECTIVE

This study aims to describe a conceptual model that could illuminate the decision process women go through when choosing to go flat on one or both sides due to breast cancer.

METHODS

A qualitative design, with constructivist grounded theory was used. Eighteen women were individually interviewed, digitally or by telephone, until saturation was reached. Data were analysed using a constant comparative iterative method in accordance with grounded theory. By examining the text data to identify the decision process for going flat and rejecting reconstructive surgery open coding was obtained. As the study proceeded patterns were explored and categories developed into a core category.

RESULTS

The overall decision process for women choosing to go flat on one or both sides emerged in three phases: Phase 1, where the women are forced to "Face the cancer", Phase 2 comprising "Reflections on health and motivation" and Phase 3, described as "Hobson's choice". The fundament of the decision process was found in the core category "Establishing and safeguarding the chosen self".

CONCLUSIONS

The decision process involved in actively going flat and rejecting reconstructive surgery is founded in the individual woman's motivations, such as view of femininity and apprehensions about the offered reconstructive surgery.

Single-incision approach to aesthetic flat closure after bilateral mastectomy in morbidly obese patients

There has been a recent emphasis to offer women who forego reconstruction after mastectomy a surgically optimized flat closure (aesthetic flat closure (AFC)). While this certainly requires attention to details not previously considered by many surgeons, additional complexity is encountered in performing this procedure in the morbidly obese patient. Most of this additional complexity revolves around resecting additional subcutaneous tissue adjacent to the breast footprint. Here, we combine two previously described techniques, one to facilitate AFC in patients with normal body mass indices (BMIs) and another approach used to facilitate removal of excess lateral subcutaneous tissue after mastectomy in patients with elevated BMIs with our single-incision approach. The single-incision approach facilitates an expedited surgical procedure and resection of excess midline tissue with more reliably symmetrical incisions bilaterally . This report describes 10 consecutive morbidly obese patients who underwent mastectomy and AFC.

"My body, my choice": A qualitative study of women's mastectomy with flat closure experiences

This qualitative study aimed to describe and explore the pre and post-mastectomy experiences of women choosing flat closure after a breast cancer diagnosis. Aesthetic flat closure creates a flat contoured chest wall after a mastectomy. There is limited research on women's flat closure experiences. To fill this gap, we interviewed 19 women (Mage = 53, range 31-72) with breast cancer who underwent a bilateral mastectomy with flat closure, examining decision-making, mirror-viewing, and flat closure experiences. Using a hermeneutic phenomenological design, we generated seven themes. Broadly, women choosing flat closure experienced pressure from their clinicians to undergo breast reconstruction. We found flat closure information to be consistently lacking. Mirror-viewing experiences of women obtaining suboptimal flat closure outcomes led to shattered expectations, mirror avoidance, psychological distress, and body image disturbances. Women negotiated their new reality by discovering ways to feel comfortable with their flat bodies. Regardless of surgical outcome, decision satisfaction was high. These findings illustrate the importance of bodily autonomy and supportive healthcare environments for women making flat closure decisions. Providing comprehensive information on all surgical options and addressing post-operative expectations can improve women's decision-making and mirror-viewing experiences and assist women in adapting to their new body image.